Federal health and safety investigators want a court to grant access to the cockpit voice recorder of the doomed ORNGE air ambulance flight that crashed and killed four men in Moosonee, Ont., in 2013.
In making the request to the court, the lead investigator has laid out what people he interviewed suggest contributed to the crash: How a combination of poor training and spatial disorientation likely led to the deaths of ORNGE Capt. Don Filliter, first officer Jacques Dupuy and flight paramedics Dustin Dagenais and Chris Snowball. And how management at ORNGE contributed to the problem.
“The problem, in part, stemmed from the fact that the people running the show didn’t have the appropriate background. Because of this, they didn’t understand the constraints and the risks of flying up north,” investigator Domenic Iacobellis, a federal health and safety official, wrote in his affidavit filed in the Superior Court of Justice, citing his interviews of experienced pilots, including the former safety manager of ORNGE.
ORNGE was charged in 2014 with 17 federal health and safety violations under the Canada Labour Code related to the crash of the chopper, which was on its way to pick up a patient. Before those charges hit court, investigators want to add the cockpit voice recording to their evidence brief. That poses a problem. So far, the only investigation team that has heard the recordings is the Transportation Safety Board of Canada, which is doing its own probe. That probe, with no sign of a report, is now the longest-running aviation accident investigation in Canada.
Investigators say they want the recording to help them determine which pilot was flying, whether there were any mechanical difficulties encountered, and “whether the pilots were aware of the helicopter’s altitude, attitude, and direction to travel in the moments leading up to the crash.”
One scenario under investigation by the health and safety team is that the pilot lacked experience in a difficult night-time takeoff — in effect, he was flying blind and to counter the incorrect perception that the nose of the helicopter was rising, pointed it down and flew the aircraft into the ground.
Another scenario is a phenomenon known as the “lean.” This “sensory illusion” takes place when a pilot goes into a turn in the dark with no visual cues available. Though ORNGE is just now experimenting with night vision goggles, they were not used by the air ambulance in 2013. With a “lean,” the pilot’s internal sensory mechanism fails and the pilot becomes immediately, and frighteningly, disoriented, the affidavit states.
A veteran Royal Canadian Air Force pilot who was consulted by the investigative team stated that the “lean” can cause a pilot to overcorrect. “This can cause the aircraft to turn too much and the pilot can quickly lose control and crash, because he does not know where he is, which direction he is pointing or turning, and where the ground might be.”
It’s rare in Canada for cockpit voice recorders to be released. Iacobellis and his team want access to determine which of the two pilots was flying, and what, if anything, was said before the crash.
A spokesman for the Transportation Safety Board said no comment could be made on the court action. He directed the Star to the board’s website, which states that under the safety board’s legislation the information contained on cockpit voice recorders is “considered to be privileged and can only be released by the board when the board considers it necessary in the interests of transportation safety.”
The affidavit in the ORNGE case notes that a court order is needed before the recordings can be released.
Soon after the accident, the Toronto Star’s Bruce Campion Smith interviewed veteran helicopter pilots who said the two ORNGE pilots would have faced an inky, disorienting darkness soon after takeoff from the remote airport.
According to the affidavit, helicopter pilots taking off from Moosonee and headed on a short hop to Attawapiskat must turn left, right after takeoff. At night, it becomes “pitch black” instantly. “The only way to turn safely in these conditions is to get a good rate of climb,” the investigators write.
Deprived of sensory input, flying blind, the tendency might be to overcorrect on a turn, or to pitch the aircraft forward and into the ground. There is no electronic beacon at Moosonee, so the aircraft’s instruments have nothing to locate, the affidavit states.
Though the person listed as pilot that night, Don Filliter, was an experienced aviator, he had not flown out of Moosonee recently and it was his first time flying this type of helicopter (Sikorsky-76A) in three years. He had just rejoined ORNGE after working for a government ministry as a pilot and his previous night experience was often with night vision goggles, which ORNGE did not have.
The investigators also raise concerns with the level of training (on a simulator) provided to the person listed as co-pilot, Jacques Dupuy.
The investigators also note that ORNGE insiders had warned the air ambulance service that “night operations were the single greatest danger. Despite this (ORNGE) was regularly making routine patient transfers in the middle of the night.” No patient was on board the night of this crash.
As the Star previously reported, investigators allege ORNGE violated its own “green-on-green” policy, meant to prevent the pairing of two pilots relatively new to their flying positions.
ORNGE told the Star it could not comment on the request for the voice recordings, which will be heard in court later in the winter.
“In May 2014, ORNGE received a summons with respect to charges laid in connection with the accident under the Canada Labour Code’s occupational health and safety provisions. ORNGE intends to defend these charges. As this matter is before the courts, it would be inappropriate to comment further. We have been made aware that the Crown is seeking a court order for the Transportation Safety Board of Canada to produce the contents of the Cockpit Voice Recorder (CVR) from the Moosonee helicopter. ORNGE is monitoring but not participating in these proceedings,” reads a statement from ORNGE.
“Our thoughts continue to be with the families of our Moosonee crew members,” said ORNGE spokesman James MacDonald.